Neonatal abstinence syndrome: Pharmacologic strategies for the mother and infant

Abstract

Opioid use in pregnancy has increased dramatically over the past decade. Since prenatal opioid use is associated with numerous obstetrical and neonatal complications, this now has become a major public health problem. In particular, in utero opioid exposure can result in neonatal abstinence syndrome (NAS) which is a serious condition characterized by central nervous system hyperirritability and autonomic nervous system dysfunction. The present review seeks to define current practices regarding the approach to the pregnant mother and neonate with prenatal opiate exposure. Although the cornerstone of prenatal management of opioid dependence is opioid maintenance therapy, the ideal agent has yet to be definitively established. Pharmacologic management of NAS is also highly variable and may include an opioid, barbiturate, and/or α-agonist. Genetic factors appear to be associated with the incidence and severity of NAS. Establishing pharmacogenetic risk factors for the development of NAS has the potential for creating opportunities for “personalized genomic medicine” and novel, individualized therapeutic interventions.

Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies

“…Morphine, a full μ‐opioid receptor agonist, is the first‐choice drug for treatment of NAS . Its pharmacokinetic properties are well studied in neonatology . Since it has a short half‐life agent, it is easy to titrate to clinical response but requires frequent administration (every 3–4 hrs), preferably by the oral route …”

“…On the other hand, significant variability in oral methadone pharmacokinetics has been shown both in adults and children, which becomes an issue of concern . At present, data on the potential superiority of methadone versus morphine for reducing the length of NAS treatment are conflicting and inconclusive . A multicenter randomized controlled trial (ClinicalTrials.gov identifier NCT01958476) is ongoing to compare morphine and methadone as treatment options for NAS…”

“…Combined inpatient‐outpatient strategies have been described such as discharge home with the newborn on maintenance therapy and subsequent regular ambulatory follow‐up . Although not yet recommended due to the dearth of evidence on their safety, home‐based detoxification programs have been explored . In select cases in which neonatal safety can be guaranteed, this approach seems feasible.…”

In Utero Oxcarbazepine Exposure and Neonatal Abstinence Syndrome: Case Report and Brief Review of the Literature

“…Morphine and methadone are first‐line pharmacologic treatments for NAS due to opioid withdrawal, and phenobarbital is the primary choice for the treatment of NAS induced by nonopioid drugs or can serve as an adjunct for neonatal opioid withdrawal . Currently, the consensus is that the use of a standardized institutional protocol based on best practice is more important than the use of a specific drug for the pharmacologic treatment of NAS . In addition to pharmacologic treatments, other supportive interventions, such as swaddling, breastfeeding, soothing behaviors, positional support, and small and frequent hypercaloric feedings, may be beneficial to relieve the symptoms of NAS .…”

Novel biomarkers to assess in utero effects of maternal opioid use: First steps toward understanding short‐ and long‐term neurodevelopmental sequelae

“…[2][3][4] Extended hospitalizations associated with NAS contribute to the financial burden of addiction on our society. 7 In utero opioid exposure has been associated with reduced brain volumes 8 and abnormal childhood neurodevelopment/cognitive function. 5,6 Identifying the best treatment options for mothers and newborns exposed to opioids remains highly debated.…”